Surveillance Definitions

Healthcare-associated
Infections:
Definitions and Standardizations
Jodor A. Lim MD., FPCP., FPSMID
PHICS Annual Convention
May 18, 2017
Crowne Plaza

Objectives
• To present standard terminologies in the
surveillance of health care associated infections
• To review the definitions of device related
infections
• To review the definition of Surgical Site infections
• To present the formulas for device related
infections and SSI’s

References
• CDC/NHSN Surveillance Definitions.
January 2017

Five (5) Figures required by the
DOH
1. CRBSI rate (per 1000 central line days)
2. CAUTI rate (per 1000 catheter days)
3. VAP rate (per 1000 ventilator days)
4. SSI rate (%)
5. HAI rate (%)
Surveillance of HAIs

BSI Key Terms
5
• Date of Event- the date when the first element used to meet
the NHSN site-specific infection criterion occurs for the first
time in the Infection Window Period
• Infection Window Period- 7-day period in which all infection
criterion must be met. It includes the date of the first positive
diagnostic test.
• POA- date of event occurs on the day of admission or day after
admission. POA period continues to include day of admission,
2 days before and the day after admission
• HAI- date of event occurs on or after the 3rd of admission
• RIT (Repeat Infection Timeframe) - 14-day timeframe during
which no new infections of the same type are reported

Present on Admission (POA)
• An infection is considered present on
admission (POA) if the date of event of the
NHSN site specific infection criterion occurs
during the POA time period, defined as day of
admission, 2 days before admission and
calendar day after admission

Date of Event Classification
Hospital Day Date of Event
Assignment
Classification
2 days before
admission
Hospital day 1
1 day before
admission
Hospital day 1
1 admission Hospital Day 1
2 Hospital Day 2
3 Hospital day 3
4 Hospital Day 4
5 Hospital day 5

Assignment for RIT
Classification
2 days before
admission
Hospital day 1
1 day before
admission
Hospital day 1 Present on
Admission (POA)
2 Hospital Day 2
3 Hospital day 3
4 Hospital Day 4
5 Hospital day 5

Healthcare Associated Infection
(HAI)
•An infection is considered a Healthcare –
Associated Infection (HAI) if the date of event
of the NHSN site specific infection criterion
occurs on or after the 3rd calendar day of
admission, where day of admission is calendar
day 1

Assignment for RIT
Classification
2 days before
admission
Hospital day 1
1 day before
admission
Hospital day 1 Present on
Admission (POA)
2 Hospital Day 2
3 Hospital day 3 Healthcare –
associated
Infection (HAI)
4 Hospital Day 4
5 Hospital day 5

Healthcare-Associated Infection (HAI)
Infection that occurs on or after the 3rd calendar day
of admission to an inpatient location where day of
admission is calendar Day 1
Day 1 Day 2 Day 3 Day 4 Day 5
Day of
admission
Date of
event
U.S. CDC NSHN Surveillance. Identifying Healthcare-associated Infections (HAI) for
NHSN Surveillance. January 2017.

All criteria should be fulfilled within a 7-day window
period (infection window period)
For VAP, it’s just 5 days.
Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Day 11
Date of
event
Day 3 Day 4 Day 5 Day 6 Day 7
Date of
event

Infection Window Period
• the 7 days during which ALL site specific infection
criteria must be met
• Includes the date of first positive diagnostic test used as
an element of site specific infection criterion was
obtained
• Lab specimen collection
• Imaging test
• Procedure or exam
• Physician diagnosis
• Initiation of treatment
• It includes the 3 calendar days before and 3 calendar
days after

Date of Event
All criteria should be fulfilled within a 7-day window
period
Date of
event
The date the first element used to meet an NHSN site
specific infection criterion occurs for the first time
within the seven day infection window period

Healthcare-Associated Infections
1. CLABSI
2. CAUTI
3. VAP
4. SSI
5. HAP
Device-associated infections

Central Line
An intravascular catheter that terminates at or
close to the heart or in one of the great
vessels which is used for infusion, withdrawal
of blood, or hemodynamic monitoring.

Great vessels
• Aorta
• Pulmonary artery
• Superior vena cava
• Inferior vena cava
• Brachiocephalic veins
• Internal jugular veins
• Subclavian veins
• External iliac veins
• Common iliac veins
• Femoral veins
• In neonates, the
umbilical
artery/vein

NOT Central Lines
• Pacemaker wires and other non-lumened devices
(no fluids infused, pushed, nor withdrawn)
• Extracorporeal membrane oxygenation (ECMO)
• Femoral arterial catheters
• Intra-aortic balloon pump (IABP) devices.
• Hemodialysis reliable outflow (HeRO) dialysis
catheters

Central line-associated
bloodstream infection (CLABSI)
• CL in place for >2 calendar days on the date of
infection/growth, with day of device placement
being Day 1 AND the CL was in place:
oOn the date of event OR
othe day before
• Organism cultured from blood is not related to an
infection at another site
Same common commensal (i.e., diphtheroids
[Corynebacterium spp. not C. diphtheriae],
Bacillus spp., Propionibacterium spp., CONS,
viridans group streptococci, Aerococcus spp., and
Micrococcus spp.) is cultured from two or more
blood cultures drawn on separate occasions
Patient has a recognized
pathogen cultured from
one or more blood
cultures

Central lines that are
removed and reinserted
= risk for CLABSI

Central lines that are
removed and reinserted
• If, after CL removal, the patient is without a central
line for at least one full calendar day (NOT to be
read as 24 hours), then the CL day count will start
anew. If instead, a new central line is inserted
before a full calendar day without a central line has
passed, the central line day count will continue.

Central Line-Associated
Bloodstream Infection (CLABSI) cont’d
24
• If patient is admitted or transferred into a facility with an
implanted central line (port) in place, and that is the patient’s
only central line, the day of first access in an inpatient location
is considered Day 1.
• Access is defined as line placement, infusion or withdrawal
through the line. Such lines continue to eligible for CLABSI
once they are accessed until patient is discharged or line is
discontinued.

1. Blood and site-specific specimen cultures match for at least one organism.
Ex: Patient with symptomatic UTI (suprapubic tenderness and >105 CFU/ml of E. coli)
and blood culture collected grows E. coli and P. aeruginosa. This is an HAI SUTI with a
secondary BSI and the reported organisms are E. coli and P. aeruginosa, since both
site and blood culture are positive for at least one matching pathogen.
2. Blood and site-specific specimen cultures do not match BUT the blood isolate
can be attributed to the distant site of infection.
Ex1: Post-op patient becomes develops fever and abdominal pain. Blood and an
aseptically-obtained T-tube drainage specimen are collected for culture. A CT scan
done that day shows fluid collection suggestive of infection. Culture results show E.
coli from the T-tube drainage specimen and blood grows Bacteroides fragilis.
Ex2: Patient has new-onset fever, cough and new infiltrates on CXR. Blood and BAL
cultures are collected. Culture results show Klebsiella pneumoniae > 104 cfu/ml from
the BAL and Pseudomonas aeruginosa from the blood.
• CL in place for >2 calendar days on the date of
infection/growth, with day of device placement
being Day 1 AND the CL was in place:
oOn the date of event OR
othe day before
• Organism cultured from blood is not related to an
infection at another site

Determining BSI
What is the date of
event?
What is the
Infection Window
Period?
What is the RIT?
What type of
event?
LCBI 1
26
InfectionWindow
RIT
Day of Discharge Device LOC
Day 6
Day 7
Day 8
Day 9
Day 10
Re-admission
CL in place ED to ICU
BC drawn; no growth
fever, pain, nausea,
hypotension
Day 11 CL in place ICU
Day 13 CL in place ICU BC drawn; E. coli
Remember!!
There is not Secondary BSI Attribution
Period for LCBI 1

CLABSI RATE
The CLABSI rate per 1000 central line days is
calculated by dividing the number of CLABSIs
by the number of central line days and
multiplying the result by 1000.
The Central Line Utilization Ratio is calculated
by dividing the number of central line days
by the number of patient days.

CLABSI RATE
Denominator Data Collection Method
Details
Manual, Daily (i.e., collected at the same time
every day of the month)
Denominator data are collected at the same
time, every day, per location.

Infection Rates by Device Days
*CL Assoc BSI rate = # of BSI in pt with cath x 1000
# of central line days
*Catheter–assoc UTI rate = # of UTI in pts with FC x 1000
# of FC days
*Vent Assoc Event rate= # of VAE in pt on Vent x 1000
# of ventilator days

Catheter-associated UTI (CAUTI)
All three (3) parameters should be present:
1. Patient had an indwelling urinary catheter that had been in place
for > 2 days and either:
Still present on the date of event† OR
Removed the day before the date of event‡
2. Patient has at least one of the following signs or symptoms
• Fever (>38.0°C)
• suprapubic tenderness
• Costovertebral angle pain or tenderness*
• Urinary urgency*
• Urinary frequency*
• Dysuria
3. Patient has a urine culture with no more than two species of
organisms, at least one of which is a bacteria of ≥105 CFU/ml.

Catheter Associated UTI (CAUTI)
7 day infection window period
14 day RIT
on IFC on IFC on IFC
Date of
Event
HYPO
TENSION

Ventilator Associated Pneumonia
(VAP)
• important, common healthcare associated
infections,
• challenge because of the lack of objective, reliable
definitions.
• in January 2013 the National Healthcare Safety
Network (NHSN) replaced surveillance for
ventilator-associated pneumonia (VAP) in adult
inpatient locations with surveillance for ventilator-
associated events (VAE).
• As of January 2014, in-plan VAP surveillance is only
available in pediatric inpatient locations.

Ventilator-Associated
Pneumonia (VAP)
Old surveillance definition

Ventilator-Associated Pneumonia
(VAP)
• Many commonly-used VAP definitions, require
radiographic findings of pneumonia.
• Evidence suggests that chest radiograph findings do
not accurately identify VAP.
• So much subjectivity and variability inherent in
chest radiograph technique, interpretation, and
reporting

Ventilator Associated Pneumonia
(VAP)
• Major difficulty - reliance on specific clinical signs
or symptoms, which are subjective and may be
poorly or inconsistently documented in the
medical record.

Ventilator Associated Event (VAE)
• In plan surveillance conducted for mechanically-
ventilated patients in adult locations (regardless
of age) will use the Ventilator-Associated Event
(VAE) protocol
• PNEU definitions are still available for those units
seeking to conduct off plan PNEU surveillance for
mechanically-ventilated adult, pediatric and
neonatal patients and non-ventilated adults,
pediatric or neonatal patients

• The VAE surveillance definition algorithm is based
on objective, streamlined, and potentially
automatable criteria that identify a broad range of
conditions and complications occurring in
mechanically ventilated adult patients
• Several modifications to the VAE definitions have
been made since January 2013.

New surveillance definition

New surveillance definition
x

• VAEs are identified by using a combination of
objective criteria:
• deterioration in respiratory status after a period of
stability or improvement on the ventilator,
• evidence of infection or inflammation,
• and laboratory evidence of respiratory infection

• Conducting in-plan VAE surveillance means
assessing patients for the presence of ALL events
included in the algorithm
• from VAC to IVAC to PVAP.
• At this time, a unit conducting in-plan VAE surveillance
cannot decide, for example, that only surveillance for
VAC (and not for IVAC or PVAP) will be performed.

• Numerator Data: The Ventilator-Associated Event
form is used to collect and report each VAE that is
identified during the month selected for
surveillance.

• Denominator Data: Device days and patient days
are used for denominators . Ventilator days, which
are the numbers of patients managed with
ventilatory devices, are collected daily, at the same
time each day, according to the chosen location
using the appropriate form

• Data Analyses: The VAE rate per 1000 ventilator
days is calculated by dividing the number of VAEs
by the number of ventilator days and multiplying
the result by 1000 (ventilator days).
• The rate per 100 episodes of mechanical
ventilation is calculated by dividing the number of
VAEs by the number of episodes of mechanical
ventilation and multiplying the result by 100
(episodes of mechanical ventilation)

• Rates that may be appropriate for use in public
reporting, inter-facility comparisons, and pay-for-
reporting/pay-for-performance programs are the
overall VAE rate (where the numerator consists of
all events meeting at least the VAC definition)
• and the “IVACplus” rate (where the numerator
consists of all events meeting at least the IVAC
definition).

• Rates that may be appropriate for internal use
within an individual unit or facility include rates of
specific event types (e.g., events meeting only the
VAC definition, events meeting only the IVAC
definition, events meeting only the PVAP
definition).

Who is eligible for VAE?
50
• Inpatients of acute care hospitals, long term acute care
hospitals, inpatient rehabilitation facilities
• Patients in adult locations are eligible for VAE surveillance
• Pediatric patients in adult locations are included in
surveillance
• Adult patients in pediatric locations are included in pedVAP
surveillance
• Patients ventilated for ≥ 3 days
• Patients not on high frequency ventilation (HFV) or
extracorporeal life support (ECLS)

Ventilator Associated Event
(VAE)
• Ventilator: A device to assist or control respiration,
inclusive of the weaning period, through a
tracheostomy or by endotracheal intubation.
• Lung expansion devices such as intermittent
positive-pressure breathing (IPPB); nasal positive
end-expiratory pressure (nasal PEEP); and
continuous nasal positive airway pressure (CPAP,
hypoCPAP) are not considered ventilators unless
delivered via tracheostomy or endotracheal
intubation (e.g., ET-CPAP, ET-BIPAP).

VAE Definition Algorithm Summary
52
Positive results of microbiological testing
Possible Ventilator Associated Pneumonia (PVAP)
General evidence of infection/inflammation
Infection-related Ventilator-Associated Complication
Ventilator Associated Condition (VAC)
Patient on Mechanical ventilation > 2 days
Baseline period of stability or improvement,
followed by sustained period of worsening oxygenation
Respiratory
Status
Component
Infection
Inflammation
Component
Additional
evidence
FIO2 or
Peep

Date of Event
53
• Date of event of worsening oxygenation (day 1 of the required
≥ 2 day period)
• Earliest date of event for VAE is mechanical ventilation day 3
(first day of worsening Oxygenation)
• First possible day that VAC criteria can be fulfilled is
mechanical ventilation day 4

14-Day VAE Event Period
54
• Date of event sets VAE Event Period
• VAE Event Period is the timeframe during which criteria for
other events--- IVAC, PVAP----must be met
• Each VAE Event Period is a 14-day in duration
• Day 1 is the date of event
• Cannot upgrade VAE on data collected outside of VAE Event
Period
• Blood cultures must be collected during the 14-day event
period for a BSI to be secondary to VAE

VAE Surveillance Algorithm: (VAE)
55

VAE Surveillance Algorithm: IVAC
56

VAE Surveillance Algorithm: PVAP
57

VAE Surveillance Algorithm: PVAP
58

• There are three criteria that can be used to meet the
PVAP definition (Figure 1):
• Criterion 1: Positive culture meeting specific
quantitative or semi-quantitative threshold (Table 3);
• Criterion 2: Purulent respiratory secretions AND
identification of organisms NOT meeting the
quantitative or semi-quantitative thresholds specified
in Table 3;
• Criterion 3: Organisms identified from pleural fluid
specimen, positive lung histopathology, and positive
diagnostic test for Legionella species or selected
respiratory viruses.

IVAC New Antimicrobials
60
• New antimicrobial is any agent listed in the protocol Appendix
that is initiated on or after the third calendar day of
mechanical ventilation and in the VAE Window Period
• Considered new if it was not given to patient on either days
preceding the current start date
• Must be continued for ≥ 4 consecutive days
• No requirement that the same antimicrobial be given on all
4 consecutive days
• Administered IV, IM digestive tract or respiratory tract

PVAP
61
• VAC and IVAC must be met
• Laboratory test collection dates must occur
• On or after calendar day 3 of ventilation and within 2
calendar days before or after onset of worsening
oxygenation (VAE Window Period)
• Organism exclusions must be considered
• Normal respiratory/oral flora, mixed respiratory/oral flora
• Candida species or yeast not otherwise specified, coag-
neg Staph species, Enterococcus species, unless isolated
from lung tissue or pleural fluid
• Community-associated pathogens

VAE Summary
62
Patient must be ventilated for more than 2 calendar days
Patient must have ≥ 2 calendar days of stability or
improvement of oxygenation immediately followed by ≥ 2
calendar days of worsening oxygenation
Earliest date of event for VAE is mechanical ventilation day 3

Surgical Site Infections (SSIs)

SSIs: Types
•Superficial incisional SSI
•Deep incisional SSI
•Organ/Space SSI

Superficial Incisional SSIs:
Infection occurs within 30 days after operative procedure (where day 1 = the procedure date)
AND
involves only skin and subcutaneous tissue of the incision
AND
patient has at least one of the following:
a. purulent drainage from the superficial incision.
b. organisms isolated from an aseptically-obtained culture from the superficial incision or
subcutaneous tissue.
c. superficial incision that is deliberately opened by a surgeon, attending physician** or other
designee and is culture positive or not cultured
AND
patient has at least one of the following signs or symptoms: pain or tenderness; localized
swelling; erythema; or heat. A culture negative finding does not meet this criterion.
d. diagnosis of a superficial incisional SSI by the surgeon or attending physician** or other
designee.

Deep Incisional SSIs:
Infection occurs within 30 days after operative procedure (where day 1 = the
procedure date)
AND
involves deep soft tissues of the incision (e.g., fascial and muscle layers)
AND
a. purulent drainage from the deep incision.
b. a deep incision that spontaneously dehisces, or is deliberately opened or aspirated
by a surgeon, attending physician** or other designee and is culture positive or not
cultured
AND
patient has at least one of the following signs or symptoms: fever (>38°C); localized
pain or
tenderness. A culture negative finding does not meet this criterion.
c. an abscess or other evidence of infection involving the deep incision that is
detected on gross anatomical or histopathologic exam, or imaging test.

Organ/Space SSIs:
Infection occurs within 30 or 90 days after the NHSN operative procedure (where day 1 = the
procedure date) according to the list in Table 3
AND
infection involves any part of the body deeper than the fascial/muscle layers, that is opened
or manipulated during the operative procedure
AND
a. purulent drainage from a drain that is placed into the organ/space (e.g., closed suction
drainage system, open drain, T-tube drain, CT guided drainage)
b. organisms isolated from an aseptically-obtained culture of fluid or tissue in the
organ/space
c. an abscess or other evidence of infection involving the organ/space that is detected on
gross anatomical or histopathologic exam, or imaging test
AND
Finding consistent with infection of that particular organ involved

Surgical Site Infections (SSIs)
• You may opt to monitor only certain types of
procedure. List them in your report.
• You may also categorize the operative procedure
(denominator) based on:
• ASA
• +/- DM
• Duration of OR
• Wound class
• Infection present at the time of surgery
• If there is multi-level infection, report the deepest
level of infection.

HAI’s
1. Provide details about your report (in the title):
• Time period
• Location
• Type of surveillance performed
“Healthcare-associated infection rates in the
[ICU/MICU/Ward] Section of [name of hospital] from
[indicate time period] generated through [type of
surveillance] surveillance conducted [frequency of
surveillance, e.g. monthly, quarterly, etc.]

HAI’s
2. Clinical diagnosis of HAIs may not be
consistent with the surveillance diagnosis.
In such cases, the infection control
physician shall make the final call if the
case is an HAI or not.

HAI’s
3. In reporting the HAI rate (%), describe your
numerator.
No. of infections
HAI = -----------------------------------
No. of discharges
e.g.1. The number of HAIs reported is the sum
of all device-related infections and SSIs only.
e.g.2. The number reported above represents
the sum of all HAIs which include device-related
infections, SSIs and HAPs.

Summary
• Presented some standard terminologies in the
surveillance of health care associated infections
• Reviewed the definitions of device related
infections - CLABSI, CAUTI, & VAE, which are
different from clinical definitions
• Reviewed the definition of Surgical Site infections
• Present the formulas for device related infections
and SSI’s

Acknowledgement
•Dr. Dessi Roman
•Ms Teresa Fox

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